Residency Insight -- A PRESENT Podiatry eZine

Jay Lieberman, DPM, FACFAS,
Director of Podiatric
Medical Education,
Northwest Medical Ctr.

YOU’RE OUT OF HERE
The New Way to Manage Time
in the Treatment Room

Psychologists use a great strategy. After 45 minutes or so of therapy, they say “that’s all the time we have for today”. With the advent of higher copays, patients today want all of their ailments cared for during one individual visit. Often patients come equipped with lists of ten or so ailments and they want each problem taken care of during their one visit. Don’t misunderstand me, I have nothing against the lists per se, my problem is with the expectation that everything on the list gets taken care of in one day. For example, after attending to all their concerns, they invariably remind you that they need their nails cut and their callus reduced. Then comes the request for Lamisil, which they believe involves no more than a written Rx. To stem the wayward expectations we have this sign posted in each one of our treatment rooms.

THERE HAS GOT TO BE SOME TRADE OFF TO REDUCED FEES,
INCREASED PAPERWORK AND INCREASED RISK.

The elderly patient longs for the days when they spent twenty minutes relaxing in a whirlpool machine. After each clavus was debrided, each nail sanded, and each nail groove nail curetted, a gentle massage with scented emollient ensued. Those days are GONE WITH THE WIND!

A retired podiatrist visits my office every three to four months. He never fails to tell me about the practice he had in the garment center in New York. He charged five dollars a foot. He laughs as he thinks about how inexpensive medical care was then. He doesn’t need to recall the old days fondly. They’re back!

Sure a better than average car was $6000.00. The Five and Dime store got its name because most items were either 5 or 10 cents. You could mail a letter for 3 cents.

WHERE DID WE FOUL UP? Fixing a bunion in 1981 got you about $1275.00. Back in those days, a friend of mine would send flowers to his postoperative patients and wear a nicely tailored suit while treating his patients.

Here is my rule. Pay me under 70% of the Medicare allowable and you get a Lands End polo and a clean lab coat. That’s all. I will debride thick, painful clavus and painful mycotic nails. Ask me to clean powder build up or dirt between the toes, put emollient on the skin, or ask for a large stack of extra aperture pads and YOU’RE OUT OF HERE!

The terms “while I’m here,” “one more thing,” or “could you take a look at something on my cousin’s foot while I’m here,” really gets my goat. “Hey doc before I go….take a look at this new mark on my leg, it is getting larger and it is turning black. “It’s nothing right”? Yeah, I can make that determination with my microscopic vision.

Ask the guy to come back for a biopsy. “Nah it’s not that important”. He has no idea that that short exchange just cost you three extra paragraphs of dictation.

I treat plantar verrucae with electrodessication and or laser ablation. My staff always shows me the ridiculously low reimbursement we get for this procedure. It has been suggested to me over and over again; don’t do the procedure on the same day as the initial consultation. Well, what do you do when a frightened eight year old with a resilient verrucae is sitting in your chair expecting the worst? Great idea, make her wait a week before doing the procedure she is horrified of. That will give her really sweet dreams. I know what you’re thinking; one could offer repeated chemical treatments and collect the copay for the next seven weeks. However, most of the pediatricians who refer me these patients have already tried the chemical route and are expecting me to solve the problem. So, in these cases, I suck it up. It pays dividends in good will over the long term anyway.

But what about the patient who comes in with a piece of glass in the foot that cannot be visualized clinically or radiographically? Should we clear out our entire schedule and take the patient to the OR ASAP? With the current structure of healthcare finances, we know that the patient is worried about having to pay another $50.00 co pay. But in fairness to other patients and in deference to the office workflow, a procedure like this will need to be planned for and done on another day. When you are looking for a needle in a haystack, there is no telling how long it will take. In a case like this, it is appropriate to evaluate the patient on one day and perform the procedure on another.

I love those low prices at Costco. When I am looking in their electronics section, I typically can’t find a salesman versed in high definition televisions. If I buy it, I lug it to my car with a large wagon that they provide for me. I want cheerios at a bargain price; plan to buy enough to feed a division. No soft carpet, no ceiling tiles, and a long wait at check out. No frills, just good products at a low price.

If fees continue to go down, the patient care experience must change. The appointment reminder will be made by a computer, the appointment itself will be scheduled online, and a light in the treatment room turns red when time is up. We all have to find efficiencies in our practice and these may not be agreeable to patients who are used to “the old way.” But, it’s amazing what people can get used to.

Sincerely,